Provider Demographics
NPI:1013969625
Name:GRANDLE, SUSAN BYRD (ARNP, PHD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:BYRD
Last Name:GRANDLE
Suffix:
Gender:F
Credentials:ARNP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5622 N PORTLAND AVE
Mailing Address - Street 2:@102
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2096
Mailing Address - Country:US
Mailing Address - Phone:405-917-7590
Mailing Address - Fax:405-917-7595
Practice Address - Street 1:5622 N PORTLAND AVE
Practice Address - Street 2:#102
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2096
Practice Address - Country:US
Practice Address - Phone:405-917-7590
Practice Address - Fax:405-917-7595
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OKR0028064363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKMB0322987OtherDEA
OKP02494Medicare UPIN